Heller myotomy for esophageal achalasia: risk factors for reintervention – a narrative review

Introduction: Heller myotomy (HM) is an effective and durable treatment for esophageal achalasia. However, some patients experience persistent or recurrent symptoms that require reintervention. Heterogeneous definitions of failure after HM limit comparability across studies and complicate clinical decision-making. Areas covered: This narrative review examines definitions and incidence of failure after HM, as well as risk factors for reintervention. Failure is influenced by disease severity, esophageal morphology, manometric type, prior endoscopic therapy, surgical technique, and center experience. Reported failure rates vary because of inconsistent definitions, follow-up durations, and patient selection. Symptom-based tools, such as the Eckardt Score, remain central but have limitations, underscoring the need for validated measures. Sigmoid esophagus and type I-III achalasia increase the risk of failure, whereas prior endoscopic therapy does not predict adverse outcomes in high-volume centers. Compared with endoscopic myotomy, HM-fundoplication may reduce postoperative reflux. Expert opinion: Achalasia is irreversible, and treatment is palliative. Laparoscopic HM remains the gold standard, though failures occur, often due to incomplete myotomy or advanced disease. Early intervention, accurate diagnosis, and meticulous surgical technique are essential. Future research should prioritize standardized definitions of failure, type-specific outcome reporting, and long-term follow-up to enhance comparability and guide management.